Daniel Mattin, of Guildford, was 19 when he died. Photo supplied by family.

By Julie Armstrong

local democracy reporter

“Tell [her] I love her” were the last words of a teenager who jumped to his death after being mistakenly released from a mental health hospital.

An inquest heard from the mental health nurse who had gone to look for 19-year-old Daniel Mattin when he had failed to return to Farnham Road Hospital by the time agreed.

Kishan Gnanasekaran, the clinical team lead on the ward where Daniel had been admitted, went out in his car to search for him and said he knew where to head to.

He found the teen sitting against a wall near the top level of a Guildford building and recounted to Surrey’s coroner’s court on Tuesday (May 31) the moments leading up to the teen’s death and his attempts to resuscitate him.

He said when he found Daniel, who had readings of alcohol in his system at two and a half times the legal limit to drive, the teenager “seemed calm”.

When Daniel stood up and the witness realised what he was going to do, he told the court: “I told him to wait. I said: ‘No, wait Daniel.’ But he didn’t.”

The court had previously heard about the close platonic relationship Daniel had formed with a fellow patient that we are legally required to refer to as Miss L.

Mr Gnanasekaran said: “He told me to tell Miss L that he loved her.”

Daniel’s parents had left the room for the nurse’s testimony.

The inquest had previously heard that a key handover document relating to plans for managing Daniel’s situation was “out of date” after he had told another patient at the hospital he “planned to be dead… in a few days whether he was an in-patient or not”.

Mr Gnanasekaran confirmed he had been aware of concerns around suicide ideation in Daniel from June 1, just days before his death on June 4 2021.

He also said he was aware of the plan to use Section 5 powers of the Mental Health Act if necessary to stop Daniel leaving the hospital if he asked to.

He could not answer why the student nurse who had given Daniel permission to leave the hospital did not have that information but said: “The reality is the dynamics can change quite quickly.”

Adding that it wasn’t very common for student nurses to allow patients to leave the hospital and he believed he would challenge it if it came up at another time, he said he couldn’t remember another specific occasion of it happening.

He said once he had found Daniel, he had to weigh up being near enough to intervene but not getting too close to Daniel, who had told him not to come any closer.

“From me getting out of the car it was a matter of seconds,” he told the jury.

He then said everything from the point Daniel let go “seemed like a long time”, as he took the stairs to the ground floor and called emergency services on loudspeaker to let them know what had happened.

He attempted to resuscitate Daniel but said the ambulance arrived shortly afterwards.

The court also heard from Dr Laurence Mynors-Wallis, a court-appointed expert and consultant psychiatrist.

He spoke about the difficulties in assessing Daniel for clinical staff, because he didn’t present with symptoms of depression but could have been masking them.

He said the hospital’s decision to start him on anti-depressants as a safeguard was the “sensible thing to do” and said it was positive that Daniel had undergone detailed psychiatric assessment.

He said professionals would have been trying to establish if there was a personality disorder that was leading Daniel to consider suicide, rather than an illness that would have been “easier to treat”.

He said when a patient is discharged from a section order, as Daniel had been, it “doesn’t mean all is well but the patient has agreed to work with clinicians.”

He was staying at the hospital voluntarily and the plan devised by his doctor was that if Daniel asked to leave, and could not be persuaded to stay, then powers to keep him at the hospital should be used.

The inquest continues.